Treating pain without addressing suffering

Suffering ceases to be suffering in some way at the moment it finds a meaning.
-Viktor Frankl

It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.
-William Osler

Back in the 1990s when pain was the newest vital sign, physicians were mandated to treat it, often with powerful medications and without truly understanding the cause and significance of the pain for individual patients.

Plato and Aristotle didn’t include pain as one of the senses, but described it as an emotion. The word “pain” is derived from Poine or Poena, the Greek goddess of revenge and the Roman spirit of punishment. Her name is also the origin of the word penalty.

Of course, pain was never measured objectively in antiquity or when it became a “vital sign” a couple of decades ago. It still can’t be measured, which makes it no more of an objective clinical sign than someone guessing their temperature without a thermometer.

“Pain and suffering” is a legal constellation that equates the significance of the two afflictions. Doctors, however, have wanted to think of the two as separate, one or the other, treated differently. In many instances, doctors treated only one — the one we call pain — and skirted around the other. We have pain specialists, but perhaps only end-of-life care formally addresses suffering; it is seldom a topic in everyday medicine.

How many times, when a patient has said “I hurt” have I asked “where” instead of “how” or “tell me more,” assuming the chief complaint is physical.

How many patients with chronic pain are unrelieved by our usual pain medications? And how many of them receive the label “psychosomatic,” but little help from their doctors?

A few weeks ago, I came across a short piece by Dr. Thomas H. Lee in the New England Journal of Medicine about suffering. I have continued to think about it ever since.

I think medicine embraced pain assessment and pain treatment in a way that overcompensated for our ineptitude at mitigating suffering. Even as we treat patients’ pain, we sometimes cause suffering through the dehumanizing way our clinics and hospitals work.

Eric Cassell describes suffering as something that happens when our personhood is threatened. Sometimes physical pain, disability or the threat of dying is the cause of suffering, but sometimes the threat to personhood is loss in other spheres. In order to alleviate suffering, physicians need to understand something about the nature and meaning of this threat.

Doctors in our era are trained to treat diseases. We are not often formally trained to explore the person with the disease; this is something we are left to discover on our own, when the disease paradigm doesn’t seem to fit the patient we are trying to help.

The movement we now call narrative medicine is focused on the subjective meaning of disease and suffering. It offers a way out of the mechanized mindset of evidence-based medicine that is built solely around the lowest common denominators of diagnoses and treatments. The corporate-scientific medicine of today dismisses the statistical outliers and individual variations between patients in its efforts to help the greatest number of individuals, instead of each particular patient in the physician’s exam room.

Doctoring is a personal calling, built on personal relationships. Even statistical outliers deserve health care that works for them, and suffering can never be understood or mitigated without first seeking knowledge of the suffering person’s own fears and beliefs.

Eric Cassell writes:

The doctor-patient relationship is the vehicle through which the relief of suffering is achieved. One cannot avoid ’becoming involved’ with the patient and at the same time effectively deal with suffering.

How many doctors are comfortable getting that involved? And how many health care organizations see that as the role of their physicians?

Treating pain without addressing suffering 3 comments

Great article!
I think the relief of suffering is being decoupled from medical care delivered by physicians and delegated to patients and families by the new, and less personal by design, paradigm of “corporate-scientific medicine of today” (not sure about scientific being an appropriate qualifier here). It’s cheaper that way.

Margaret Fleming

If I were the sort to embroider pillows, that Osler quote would probably be all over the place. Like on a shirt I’d wear to the office of a doctor I’m meeting for the first time. Luckily, I’ve learned to listen closely, and have said goodbye to at least one doctor who enjoys disease more than people. Blessedly, I’ve found at least one doctor in my new state of TX, who is interested in people, and I remember with love the ones in CA who are dedicated to knowing the person,.

Robert Luedecke

Very nice article. As a physician who personally has chronic pain, I think it is important for all of us to realize that the strange symptoms we are hearing about today may be part of a pain syndrome that is not well described until tomorrow. I was very hesitant to tell my doctor my very bizarre-sounding symptoms and then relieved for him to tell me there are some head and neck pain problems that are just beginning to be understood. An earlier doctor told me it was not possible to have pain in the areas where I hurt. Please treat your patients kindly even if it is not entirely clear what is happening.